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AIRCRAFT INSURANCE:
INSURED NAME
ADDRESS
PHONE
EMAIL
POLICY EXPIRATION / CLOSING DATE
AIRCRAFT YEAR, MAKE, AND MODEL
INSURED/MARKET VALUE
FAA N#
# OF SEATS
AIRPORT BASE
HANGARED OR TIED
LIMIT OF LIABILITY REQUESTED
WILL THE AIRCRAFT BE OPERATED FROM UNPAVED RUNWAYS
DOES THE AIRCRAFT HAVE AN IFR GPS WITH MOVING MAP AND 2 AXIS AUTOPILOT
AOPA #
EAA #
PILOT NAME
PILOT DOB
FAA LICENSE & TYPE RATINGS
TOTAL HOURS
TOTAL HOURS IN INSURED AIRCRAFT
TOTAL HOURS PAST 12 MONTHS
TOTAL HOURS PAST 12 MONTHS IN INSURED AIRCRAFT
DATE AND TYPE OF LAST TRAINING
ANY ACCIDENTS, INCIDENTS, DUIs, CONVICTIONS, LIMITATIONS
MULTI ENGINE TIME
RETRACTABLE GEAR TIME
ALL OF THE INFORMATION HEREIN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND I HAVE NOT KNOWINGLY OR INTENTIONALLY CONCEALED OR MISREPRESENTED ANY FACT. THIS FORM WILL BECOME PART OF THE INSURANCE APPLICATION AND AS SUCH ALL FRAUD STATEMENTS ARE APPLICABLE.
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